Healthcare Provider Details

I. General information

NPI: 1417994815
Provider Name (Legal Business Name): MITCHELL DREW MARTINEAU NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 BOATNER RD STE 114
EGLIN AFB FL
32542-1302
US

IV. Provider business mailing address

307 BOATNER RD STE 114
EGLIN AFB FL
32542-1302
US

V. Phone/Fax

Practice location:
  • Phone: 850-883-8435
  • Fax: 850-883-8311
Mailing address:
  • Phone: 850-883-8435
  • Fax: 850-883-8311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11003748
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN11003748
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number11003748
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: